Maria Teresa Congedo

An Individual Patient Data Metaanalysis of Outcomes and Prognostic Factors After Treatment of Oligometastatic Non-Small-Cell Lung Cancer.

INTRODUCTION/BACKGROUND An individual patient data metaanalysis was performed to determine clinical outcomes, and to propose a risk stratification system, related to the comprehensive treatment of patients with oligometastatic NSCLC. MATERIALS AND METHODS After a systematic review of the literature, data were obtained on 757 NSCLC patients with 1 to 5 synchronous or metachronous metastases treated with surgical metastectomy, stereotactic radiotherapy/radiosurgery, or radical external-beam radiotherapy, and curative treatment of the primary lung cancer, from hospitals worldwide. Factors predictive of overall survival (OS) and progression-free survival were evaluated using Cox regression. Risk groups were defined using recursive partitioning analysis (RPA). Analyses were conducted on training and validating sets (two-thirds and one-third of patients, respectively). RESULTS Median OS was 26 months, 1-year OS 70.2%, and 5-year OS 29.4%. Surgery was the most commonly used treatment for the primary tumor (635 patients [83.9%]) and metastases (339 patients [62.3%]). Factors predictive of OS were: synchronous versus metachronous metastases (P < .001), N-stage (P = .002), and adenocarcinoma histology (P = .036); the model remained predictive in the validation set (c-statistic = 0.682). In RPA, 3 risk groups were identified: low-risk, metachronous metastases (5-year OS, 47.8%); intermediate risk, synchronous metastases and N0 disease (5-year OS, 36.2%); and high risk, synchronous metastases and N1/N2 disease (5-year OS, 13.8%). CONCLUSION Significant OS differences were observed in oligometastatic patients stratified according to type of metastatic presentation, and N status. Long-term survival is common in selected patients with metachronous oligometastases. We propose this risk classification scheme be used in guiding selection of patients for clinical trials of ablative treatment.

Surgery for oligometastatic non-small cell lung cancer: long-term results from a single center experience.

OBJECTIVE The role of surgery in the multimodal therapy for selected stage IV oligometastatic non-small cell lung cancer (NSCLC) is still a forum of open discussion. METHODS We have retrospectively analyzed the records of 53 patients with oligometastatic NSCLC who had been treated with curative intent in the period January 1997 to May 2010. RESULTS The mean age and the male/female ratio were 61 years and 32:21, respectively. A single metastatic lesion was present in 45 (84.9%) subjects, in 2 patients there were 2 different anatomic sites involved, and in 8 patients there were 2 metastases in the same site. The most common involved sites were brain (39), followed by adrenal gland (7), bone (3), vertebrae (3), liver (1), and contralateral supraclavicular lymph node (1). Distant disease was completely resected in 42 patients; 10 patients were treated with exclusive chemotherapy and/or radiotherapy and 1 with local laser therapy. Twenty-nine patients had been administered concurrent chemoradiation in a neoadjuvant setting before the surgical treatment at the lung or both sites (primary/distant). The pulmonary resection was complete (R0) in 42 patients (79.2%). Overall, 1- and 5-year survivals were 73.1% and 24%, respectively (median follow-up, 28 months). Median overall survival, local disease-free survival, and distant disease-free survival, estimated using the Kaplan-Meier method, were respectively 19, 72, and 12 months. After stepwise multivariate analysis, the weight loss (P<.001), the completeness of pulmonary resection (P=.0019), and, interestingly, the performance of a positron emission tomography-computed tomography scan in preoperative staging (P=.05) maintained their independent prognostic value as overall survival determinants. CONCLUSIONS Surgical treatment for selected stage IV NSCLC is feasible and safe. Furthermore, good survival can be expected in those patients in whom a complete resection of the primary tumor and radical control of the distant diseases are accomplished.

Paraneoplastic Acrokeratosis (Bazex Syndrome) in Lung Cancer

A 55-year-old white man, longstanding smoker (40 cigarettes a day for 30 years), with no past or family history of psoriasis, developed scaly erythematous hyperkeratotic lesions of the periungueal region of both hands, distributed symmetrically, first affecting thumb and second finger, then involving the other fingers, except the little finger (Fig 1). These lesions worsened during 1 year; a yellowish discoloration of nails with onychodystrophy involving both hands and feet was observed, together with hyperkeratosis and thickening of palms and soles, while sparing the other acral extremities. After 5 months, the patient underwent umbilical hernioplasty, and a chest x-ray performed at this stage did not show any abnormality. The skin lesions persisted for about 3 years showing resistance to a variety of topical treatments (ie, itraconazole, tioconazole, mometason). Shortly thereafter, about 3.5 years after the skin manifestations, the patient developed a whooping cough, and a chest-x-rays revealed a mass in the upper lobe of the right lung, subsequently confirmed with a computed tomography scan also showing omolateral nodes involvement. He was referred to the Division of Thoracic Surgery, Gemelli Hospital (Rome, Italy) presenting as paronichia-like lesions. All 20 nails showed dystrophic lesions and partial onicholysis resembling psoriasis or postinflammatory paronichia. No perilesional inflammation was seen, and the patient claimed he did not have any inflammation in past. Cultural and direct examination for fungi was negative. Familiar history for psoriasis was negative, and there was not any other sign of psoriasis on the skin and the nails. The patient underwent upper right lobectomy. The postoperative pathological diagnosis was G3 adenocarcinoma of the lung T2-N0-M0; immunohistochemistry showed that constituent cells were positive for cytokeratin 7 and thyroid transcription factor 1, while negative for cytokeratin 20 and synaptophysin. A 3-month course of treatment with cisplatin and navelbine was delivered. The skin lesions drastically improved in a few months, with complete healing in July 2008 (Fig 2). The diagnosis of Bazex syndrome (BS) associated with adenocarcinoma of the lung was given. Twenty-seven-months follow-up after successful surgical resection the patient has no evidence of disease. In 1922, Gougerot and Rupp first recognized paraneoplastic acrokeratosis (PA). The eponymous of BS is ascribed to André Bazex, who reported several cases since his first description of PA associated with a metastatic pyriform sinus cancer in 1965. At the same time, the term BS may also refer to a rare genodermatosis with cancer predisposition described by the same author. In this work, 143 cases of PA have been reviewed, mostly related to supradiaphragmatic squamous cell malignancies and affecting men older than age 40 years. The association with adenocarcinoma of the lung is rare. We observed a striking case of PA whose clinical outcome diverged from the standard three-stage course originally proposed by Bazex and Griffiths. As a rule, a cutaneous paraneoplastic disorder is mostly associated with squamous cell carcinoma of the upper aerodigestive tract and is characterized by a symmetric, psoriasiform, hyperkeratotic eruption of the extremities (ears, finger, toes, nose), which may also involve trunk and limbs. Itching and paining are uncommon, although the former may occur in up to 18% of cases. Hyperkeratotic eruption is typical of BS, some unusual features of the dermatosis have been described, such as hyperpigmented papules, plaques and bullous lesions. Diagnosis is clinical, based on the patient’s medical history and physical examination, paying attention to the characteristic distribution of the lesions. Other conditions such as acral psoriasis, palmoplantar keratoderma, onychomycosis, pityriasis rubra pilaris should be ruled out. To our knowledge, only 15 women (10.6%) with BS have been reported. Although pathogenesis is still unclear, several hypotheses have been proposed, pointing out to the cross reactivity between tumoral and cutaneous antigens as responsible for the skin damage. As observed by Bazex and Griffiths, PA generally present a well-defined three-stage course. In the first stage, acral regions are first involved including nails (77%), ears (76%), fingers (65%), and nose (62%) with no clinical evidence of the underlying tumor. In the

Cushing's Syndrome due to a Bronchial ACTH-Secreting Carcinoid Successfully Treated With Radiofrequency Ablation (RFA)

CONTEXT The ectopic production of ACTH is responsible for approximately 10% of cases of Cushings syndrome. Whenever possible, once hypercortisolemia is under control with medical therapy, the final treatment consists of surgical excision of the tumor. We report a case of a patient with high surgical risk and poor response to medical therapy in which hypercortisolemia has been successfully treated with radiofrequency ablation of the bronchial carcinoid tumor. CASE PRESENTATION A 43-year-old woman came to our hospital because of severe and rapidly worsening signs and symptoms of hypercortisolism over the previous 3 months. Hormonal tests suggested the presence of Cushings syndrome due to ectopic ACTH production. Imaging studies detected an 8-mm pulmonary nodule with fluorine-18-fluorodeoxyglucose uptake localized in the middle right lobe. The patient started therapy with ketoconazole with poor response. Middle right lobectomy was indicated but, due to the patients very high surgical risk, a thermal ablation with radiofrequency of the bronchial nodule was performed. OUTCOMES AND RESULTS After the procedure, ACTH and cortisol levels dropped and fluorine-18-fluorodeoxyglucose positron emission tomography showed complete response to treatment. Clinical conditions progressively improved, and 6 weeks later, the patient underwent middle lobectomy without complications. Histology showed a 0.7-cm ACTH-producing typical bronchial carcinoid tumor. CONCLUSIONS Thermal ablation with radiofrequency allows achieving a rapid control of hypercortisolism with subsequent improvement of symptoms. This procedure should therefore be considered as a viable therapeutic option in those cases of bronchial ACTH-secreting tumors in which the surgical approach is initially contraindicated.

Bronchial Oncocytoma With High 18F-Fluorodeoxyglucose Uptake Revealed by Nephrotic Syndrome

CASE REPORT A 77-year-old nonsmoker white woman with a medical history of mild hypertensive heart disease and diabetes was referred to our hospital for diffuse edemas, cough, and persisting asthenia. No history of hemoptysis, loss of weight, loss of appetite or other constitutional symptoms was reported. A nephrotic syndrome was diagnosed, with massive proteinuria (15–20 g/day), hypoalbuminemia (2.5 g/dl), hypercreatininemia (3.4 mg/dl), and associated increase in serum lipoprotein levels. Tumor markers (CEA, Ca 19.9, Ca 125, NSE, Ca 15.3) were within normal ranges. A renal biopsy revealed a status compatible with a stage IV minimal change disease. To differentiate the idiopathic versus the secondary nature of the nephropathy, a total-body computed tomography (CT) scan was performed. An endoluminal lesion measuring 1.3 cm in the major axis was localized in the right inferior lobe (RIL) bronchus (Fig. 1). The positron emission tomography (PET)-CT scan (18F-fluorodeoxyglucose/PET-CT) characterized the RIL nodule with an standardized uptake value (SUV) of 12. No other lesions referable to local or distant metastases were detected (Fig. 2). A fiber-optic bronchos copy revealed an endobronchial red lesion localized near the origin of right B6 bronchus. Cytology performed on material obtained by endobronchial brushing was suggestive of atypical cells. Given the relatively high SUV value detected by the PET examination and the evidence of cellular atypia at the cytological examination, surgery with radical intent was performed, and a right inferior lobectomy plus systematic mediastinal lymphadenectomy realized. Final pathology confirmed an epithelial tumor characterized by extensive oncocytic features, compatible with bronchial oncocytoma (Fig. 3A–E). No hilar or mediastinal nodes were involved. The postoperative course was uneventful. Four weeks after surgery, serum albumin level increased to 3.2 g/dl, creatinine level decreased to 1.8 mg/dl, and proteinuria decreased to 1.0 g/day. One year after

Analysis of risk factors in the development of bronchopleural fistula after major anatomic lung resection: experience of a single centre

The bronchopleural fistula (BPF) is a rare but potentially fatal complication of major thoracic surgery. The purpose of this work is to investigate the risk factors associated with the development of fistulas after lobectomy and pneumonectomy.

Lung metastasectomy following kidney tumors: outcomes and prognostic factors from a single-center experience

Background The lung is one of the sites most frequently affected by metastatic renal cell carcinoma (mRCC). Nonsurgical therapy for mRCC has limited efficacy, while the 5-year survival rates data published in literature after pulmonary surgery for metastasectomy, emphasize the role of surgery as the treatment that guarantees the best effectiveness in pulmonary resectable metastases. Methods From January 2000 to March 2016, 27 patients underwent pulmonary metastasectomy for metastatic renal cancer was retrospectively reviewed. Primary renal cancer was controlled in all patients and there was no other metastatic site in addition to the lung, at the time of metastasectomy. The aim of the study was to identify outcomes and prognostic factors in association with survival after complete pulmonary resection of metastases in a subgroup of patients with isolated pulmonary metastases from RCC. Results Five- and 10-year overall survival (OS) from first pulmonary metastasectomy was 75% and 59%, respectively. Independent prognostic factor influencing survival were: dimension of pulmonary metastases ≥2 cm (3-year survival: 67% vs. 100%; P=0.014) and disease free interval (DFI) ≥5 years (3-year survival: 94% vs. 28%; P=0.05). The only independent prognostic factors affecting DFI was the dimension of pulmonary metastases ≥2 cm (5-year DFI: 67% vs. 89%; P=0.03) at univariate analysis. Conclusions Considering the good results based on high long-term efficacy and low morbidity after metastases surgical resection, we always recommend metastasectomy in patients with technically resectable metastases, especially in case of long DFI and reduced dimension of pulmonary lesions.

Giant air-inflated hydatid cyst of the lung mimicking massive pneumothorax

A 68-year-old Caucasian man was admitted to our emergency department with a 6-month history of progressive dyspnoea, tachycardia, chronic cough and purulent sputum production. The patients medical history was notable for hepatic echinococcosis diagnosed in 2002. Physical examination revealed no chest wall movement, a hyper-resonant sound on percussion, absent tactile fremitus and no audible breath sound in the right hemithorax. A slight tracheal deviation towards the left could also be felt on palpation …

Successful Three-Stage Ethanol Ablation of Esophageal Mucocele

their anatomic proximity to other vital organs, visceral vessels are rarely injured alone (1), and isolated IMA injury as a result of blunt trauma is extremely rare. To the best of our knowledge, only one case has been reported, in which the injury involved a low-speed motor vehicle accident (2). Two mechanisms have been proposed to explain traumatic visceral artery injury. The first is shearing force causing avulsion of the artery at the junction between the retroperitoneal portion and unfixed portion of the bowel. The second mechanism is compression injury, in which the artery is crushed between the object producing the blunt force and the lumbar spine, as in the present case. In cases involving visceral branch avulsion at the orifice, embolization of the lacerated arterial stump and the arterial orifice is mandatory to achieve hemostasis. Trottier et al (3) reported a similar case with renal artery avulsion. Avulsion of the right renal polar artery originating from the right common iliac artery was treated by placing a stent graft into the right common iliac artery; however, subsequent enlargement of a retroperitoneal hematoma as a result of subclinical back-bleeding from the lacerated arterial stump led to abdominal compartment syndrome. Transcatheter embolization of lacerated IMA origins is another treatment option. Hamid et al (4) reported transcatheter embolization for lumbar artery avulsion using N-butyl cyanoacrylate (Histoacryl; B. Braun Melsungen AG, Melsungen, Germany) glue injected from the artery’s origin. However, glue injection has the potential risk of unintentional distal embolization or reflux to the aorta, and transcatheter embolization using detachable microcoils might be a safer alternative. Our method is a simple and safe method of controlling hemorrhage caused by visceral branch avulsion.

Non-Small Cell Lung Cancer with Chest Wall Involvement: Integrated Treatment or Surgery Alone?

BACKGROUND  The aim of this study was to identify prognostic factors in patients affected by non-small cell lung cancer (NSCLC) with chest wall (CW) involvement, analyzing different strategies of treatment and surgical approaches. METHODS  Records of 59 patients affected by NSCLC with CW involvement underwent surgery were retrospectively reviewed, from January 2000 to March 2013. RESULTS  Induction therapy was administered to 18 (30.5%) patients while adjuvant treatment to 36 (61.0%). In 36 (61%) patients, lung resection was associated only with a parietal pleural resection while in 23 (39%) with CW en-bloc resection. Overall 5-year survival was 34%. Prognostic factors were evaluated in the 51 (86.4%) completely resected (R0) patients.Five-year survival was 60% in patients undergoing induction therapy followed by surgery and 24% in those who underwent surgery as first treatment (p = 0.11). Five-year survival was better in the neoadjuvant group than that in the surgery group in IIB (T3N0) p-stage (100 vs 28%, p = 0.03), while in the IIIA (T3N1-2,T4N0) p-stage it was of 25 vs 0%, respectively (p = 0.53).No 5-year survival difference was found in case of parietal pleural resection versus CW en-bloc resection (p = 0.27) and in case of only parietal pleural involvement versus soft tissue (p = 0.78).In case of incomplete resection (R1), patients undergoing adjuvant radiotherapy had better 2-year survival than patients untreated: 60% vs 0% (p = 0.025). CONCLUSIONS  Type of surgical resection and the deep of infiltration of disease do not influence survival in this subset of patients. Integrated treatments seem to be suitable: neoadjuvant therapies ensure a better survival rate than surgery alone in IIB and IIIA patients, instead adjuvant radiotherapy proves a fundamental option in incomplete resections.